Expanding the human gut microbiome atlas of Africa

Population studies are crucial in understanding the complex interplay between the gut microbiome and geographical, lifestyle, genetic, and environmental factors. However, populations from low- and middle-income countries, which represent ~84% of the world population, have been excluded from large-scale gut microbiome research. Here, we present the AWI-Gen 2 Microbiome Project, a cross-sectional gut microbiome study sampling 1,803 women from Burkina Faso, Ghana, Kenya, and South Africa. By intensively engaging with communities that range from rural and horticultural to urban informal settlements and post-industrial, we capture population diversity that represents a far greater breadth of the world's population. Using shotgun metagenomic sequencing, we find that study site explains substantially more microbial variation than disease status. We identify taxa with strong geographic and lifestyle associations, including loss of Treponema and Cryptobacteroides species and gain of Bifidobacterium species in urban populations. We uncover a wealth of prokaryotic and viral novelty, including 1,005 new bacterial metagenome-assembled genomes, and identify phylogeography signatures in Treponema succinifaciens. Finally, we find a microbiome signature of HIV infection that is defined by several taxa not previously associated with HIV, including Dysosmobacter welbionis and Enterocloster sp. This study represents the largest population-representative survey of gut metagenomes of African individuals to date, and paired with extensive clinical biomarkers, demographic data, and lifestyle information, provides extensive opportunity for microbiome-related discovery and research.

Impact of DREAMS interventions on attitudes towards gender norms among adolescent girls and young women: Findings from a prospective cohort in Kenya

The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS' effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017-18) and AGYW's attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.

A call-to-action: integrate a learning health system framework into longitudinal population studies to improve health response in Africa

Longitudinal population studies (LPSs) in Africa have the potential to become powerful engines of change by adopting a learning health system (LHS) framework. This is a call-to-action opinion and highlights the importance of integrating an LHS approach into LPSs, emphasizing their transformative potential to improve population health response, drive evidence-based decision making, and enhance community well-being. Operators of LPS platforms, community members, government officials, and funding agencies have a role to contribute to this transformative journey of driving evidence-based interventions, promoting health equity, and fostering long-term public health solutions for African communities.

Identifying and Characterizing the Poorest Urban Population Using National Household Surveys in 38 Cities in Sub-Saharan Africa

Identifying and classifying poor and rich groups in cities depends on several factors. Using data from available nationally representative surveys from 38 sub-Saharan African countries, we aimed to identify, through different poverty classifications, the best classification in urban and large city contexts. Additionally, we characterized the poor and rich groups in terms of living standards and schooling. We relied on absolute and relative measures in the identification process. For absolute ones, we selected people living below the poverty line, socioeconomic deprivation status and the UN-Habitat slum definition. We used different cut-off points for relative measures based on wealth distribution: 30%, 40%, 50%, and 60%. We analyzed all these measures according to the absence of electricity, improved drinking water and sanitation facilities, the proportion of children out-of-school, and any household member aged 10 or more with less than 6 years of education. We used the sample size, the gap between the poorest and richest groups, and the observed agreement between absolute and relative measures to identify the best measure. The best classification was based on 40% of the wealth since it has good discriminatory power between groups and median observed agreement higher than 60% in all selected cities. Using this measure, the median prevalence of absence of improved sanitation facilities was 82% among the poorer, and this indicator presented the highest inequalities. Educational indicators presented the lower prevalence and inequalities. Luanda, Ouagadougou, and N'Djaména were considered the worst performers, while Lagos, Douala, and Nairobi were the best performers. The higher the human development index, the lower the observed inequalities. When analyzing cities using nationally representative surveys, we recommend using the relative measure of 40% of wealth to characterize the poorest group. This classification presented large gaps in the selected outcomes and good agreement with absolute measures.

Voices and challenges of marginalized and vulnerable groups in urban informal settlements in Nairobi, Kenya: building on a spectrum of community-based participatory research approaches

Urbanization is rapidly increasing across Africa, including in Nairobi, Kenya. Many people, recent migrants and long-term residents, live within dense and dynamic urban informal settlements. These contexts are fluid and heterogeneous, and deepening the understanding of how vulnerabilities and marginalization are experienced is important to inform pointed action, service delivery and policy priorities. The aim of this paper is to explore vulnerabilities and marginalization within Korogocho and Viwandani informal settlements in Nairobi and generate lessons on the value of a spectrum of community based participatory research approaches for understanding health and well-being needs and pinpointing appropriate interventions. In the exploratory stages of our ARISE consortium research, we worked with co-researchers to use the following methods: social mapping, governance diaries, and photo voice. Social mapping (including the use of Focus Group Discussions) identified key vulnerable groups: marginalized and precarious child heads of households (CHHs), Persons with disability who face multiple discrimination and health challenges, and often isolated older adults; and their priority needs, including health, education, water and sanitation. The governance diaries generated an understanding of the perceptions of the particularly vulnerable and marginalized informal settlement residents regarding the various people and institutions with the power to influence health and wellbeing; while photo voice highlighted the lived experiences of vulnerability and marginality. Understanding and responding to fluid and intersecting marginalities and vulnerabilities within growing urban informal settlements is particularly critical to achieving inclusive urbanization, where no one is left behind, a theme central to the Sustainable Development Goals and Kenya's Vision 2030.

Policy and practices shaping the delivery of health services to pregnant adolescents in informal urban settlements in Kenya

In Kenya, the pregnancy rate of 15% among adolescents aged 15-19 years is alarmingly high. Adolescent girls living in informal urban settlements are exposed to rapid socio-economic transitions and multiple intersecting health risks and may be particularly disadvantaged in accessing sexual reproductive health services. Understanding vulnerabilities and service-seeking behaviours from different perspectives is important in order to support the development and implementation of progressive policies and services that meet adolescents' unique needs within urban informal settlements. This study explored policy makers, community health service providers' and community members' perceptions of access to, and delivery of, sexual reproductive health services for pregnant adolescents in one informal urban settlement in Nairobi. We employed qualitative methods with respondents throughout the health system, purposively sampled by gender and diversity of roles. We conducted focus group discussions with community members (n = 2 female-only; n = 2 male-only), key informant interviews with policy makers (n = 8), traditional birth attendants (n = 12), community health volunteers (CHVs) (n = 11), a nutritionist (n = 1), social workers (n = 2) and clinical officers (n = 2). We analysed the data using thematic analysis. Government policies and strategies on sexual and reproductive health for adolescents exist in Kenya and there are examples of innovative and inclusive practice within facilities. Key factors that support the provision of services to pregnant adolescents include devolved governance, and effective collaboration and partnerships, including with CHVs. However, inadequate financing and medical supplies, human resource shortages and stigmatizing attitudes from health providers and communities, mean that pregnant adolescents from informal urban settlements often miss out on critical services. The provision of quality, youth-friendly reproductive health services for this group requires policies and practice that seek to achieve reproductive justice through centring the needs and realities of pregnant adolescents, acknowledging the complex and intersecting social inequities they face.

Predictors of quality of childcare centers in low-income settings: findings from a cross-sectional study in two Nairobi slums

Background

Rapid urbanization and increased women's involvement in paid work have contributed to the upsurge of informal childcare centers, especially in low-income settings where quality is a major issue. However, there are limited data on the factors associated with the quality of childcare centers in informal settlements in Africa.

Methods

We conducted a quantitative observation and questionnaire survey of 66 childcare centers to identify the factors associated with the quality of childcare services in two informal settlements (Korogocho and Viwandani) in Nairobi. The quality of the centers (outcome variable) was assessed using a locally developed tool. Data on center characteristics including type, size, location, length of operation, charges, and number of staff were collected. Center providers' knowledge, attitude, and practices (KAP) in childcare were assessed through a questionnaire, focusing on nurturing care and business management. Data were described using means and standard deviation or frequencies and percentages. Associations between quality center score (outcome variable) and other variables were examined using multivariable linear regression to identify potential predictors of the quality of the center environment.

Findings

A total of 129 childcare centers were identified and categorized as home-based (n = 45), center-based (n = 14), school-based (n = 61), and church-based (n = 9). The number of home-based centers was particularly high in Viwandani (n = 40; 52%). Only 9% of home-based centers reported any external support and 20% had any training on early childhood development. Of the 129 centers, 66 had complete detailed assessment of predictors of quality reported here. Unadjusted linear regressions revealed associations between quality of childcare center and center providers' education level, type of center, support received, caregiver-child ratio, number of children in the center, and center providers' KAP score (p < 0.05). However, in the multivariable regression, only higher levels of center provider KAP (β = 0.51; 95% CI: 0.18, 0.84; p = 0.003) and center type (β = 8.68; 95% CI: 2.32, 15.04; p = 0.008) were significantly associated with center quality score.

Implication

Our results show that center providers' knowledge and practices are a major driver of the quality of childcare centers in informal settlements in Nairobi. Interventions for improving the quality of childcare services in such settings should invest in equipping center providers with the necessary knowledge and skills through training and supportive supervision.

SARS-CoV-2 seroprevalence and implications for population immunity: Evidence from two Health and Demographic Surveillance System sites in Kenya, February-December 2022

BACKGROUND

We sought to estimate SARS-CoV-2 antibody seroprevalence within representative samples of the Kenyan population during the third year of the COVID-19 pandemic and the second year of COVID-19 vaccine use.

METHODS

We conducted cross-sectional serosurveys among randomly selected, age-stratified samples of Health and Demographic Surveillance System (HDSS) residents in Kilifi and Nairobi. Anti-spike (anti-S) immunoglobulin G (IgG) serostatus was measured using a validated in-house ELISA and antibody concentrations estimated with reference to the WHO International Standard for anti-SARS-CoV-2 immunoglobulin.

RESULTS

HDSS residents were sampled in February-June 2022 (Kilifi HDSS N = 852; Nairobi Urban HDSS N = 851) and in August-December 2022 (N = 850 for both sites). Population-weighted coverage for ≥1 doses of COVID-19 vaccine were 11.1% (9.1-13.2%) among Kilifi HDSS residents by November 2022 and 34.2% (30.7-37.6%) among Nairobi Urban HDSS residents by December 2022. Population-weighted anti-S IgG seroprevalence among Kilifi HDSS residents increased from 69.1% (65.8-72.3%) by May 2022 to 77.4% (74.4-80.2%) by November 2022. Within the Nairobi Urban HDSS, seroprevalence by June 2022 was 88.5% (86.1-90.6%), comparable with seroprevalence by December 2022 (92.2%; 90.2-93.9%). For both surveys, seroprevalence was significantly lower among Kilifi HDSS residents than among Nairobi Urban HDSS residents, as were antibody concentrations (p < 0.001).

CONCLUSION

More than 70% of Kilifi residents and 90% of Nairobi residents were seropositive for anti-S IgG by the end of 2022. There is a potential immunity gap in rural Kenya; implementation of interventions to improve COVID-19 vaccine uptake among sub-groups at increased risk of severe COVID-19 in rural settings is recommended.

The feasibility, acceptability, cost and benefits of a "communities of practice" model for improving the quality of childcare centres: a mixed-methods study in the informal settlements in Nairobi

Background

Informal childcare centres have mushroomed in the informal settlements of Nairobi, Kenya to meet the increasing demand. However, centre providers are untrained and the facilities are below standard putting children at risk of poor health and development. We aimed to co-design and test the feasibility, acceptability, cost and potential benefits of a communities of practice (CoP) model where trained community health volunteers (CHVs) provide group training sessions to build skills and improve practices in informal childcare centres.

Methods

A CoP model was co-designed with sub-county health teams, centre providers and parents with inputs from Kidogo, government nutritionists and ECD experts and implemented in 68 childcare centres by trained CHVs. Its feasibility and potential benefits were measured quantitatively and qualitatively. Centre provider (n = 68) and CHV (n = 20) knowledge and practice scores before and after the intervention were assessed and compared. Intervention benefits were examined using linear regressions adjusting for potential confounding factors. We conducted in-depth interviews with 10 parents, 10 CHVs, 10 centre providers and 20 local government officials, and two focus groups with CHVs and centre providers. Qualitative data were analysed, focusing on feasibility, acceptability, potential benefits, challenges and ideas for improvement. Cost for delivering and accessing the intervention were examined.

Results

The intervention was acceptable and feasible to deliver within existing government community health systems; 16 CHVs successfully facilitated CoP sessions to 58 centre providers grouped into 13 groups each with 5-6 centre providers, each group receiving four sessions representing the four modules. There were significant improvements in provider knowledge and practice (effect size = 0.40; p < 0.05) and quality of centre environment (effect size = 0.56; p < 0.01) following the intervention. CHVs' scores showed no significant changes due to pre-existing high knowledge levels. Qualitative interviews also reported improvements in knowledge and practices and the desire among the different participants for the support to be continued. The total explicit costs were USD 22,598 and the total opportunity costs were USD 3,632 (IQR; USD 3,570, USD 4,049).

Conclusion

A simple model delivered by CHVs was feasible and has potential to improve the quality of informal childcare centres. Leveraging these teams and integration of the intervention into the health system is likely to enable scale-up and sustainability in Kenya and similar contexts.

Developing an intervention to improve the quality of childcare centers in resource-poor urban settings: a mixed methods study in Nairobi, Kenya

Background

Globally, 350 million under-5s do not have adequate childcare. This may damage their health and development and undermine societal and economic development. Rapid urbanization is changing patterns of work, social structures, and gender norms. Parents, mainly mothers, work long hours for insecure daily wages. To respond to increasing demand, childcare centers have sprung up in informal settlements. However, there is currently little or no support to ensure they provide safe, nurturing care accessible to low-income families. Here, we present the process of co-designing an intervention, delivered by local government community health teams to improve the quality of childcare centers and ultimately the health and development of under-5 children in informal settlements in Kenya.

Methods

This mixed methods study started with a rapid mapping of the location and basic characteristics of all childcare centers in two informal settlements in Nairobi. Qualitative interviews were conducted with parents and grandparents (n = 44), childcare providers, and community health teams (n = 44). A series of 7 co-design workshops with representatives from government and non-governmental organizations (NGOs), community health teams, and childcare providers were held to design the intervention. Questionnaires to assess the knowledge, attitudes, and practices of community health volunteers (n = 22) and childcare center providers (n = 66) were conducted.

Results

In total, 129 childcare centers were identified -55 in Korogocho and 77 in Viwandani. School-based providers dominated in Korogocho (73%) while home-based centers were prevalent in Viwandani (53%). All centers reported minimal support from any organization (19% supported) and this was particularly low among home-based (9%) and center-based (14%) providers. Home-based center providers were the least likely to be trained in early childhood development (20%), hence the co-designed intervention focused on supporting these centers. All co-design stakeholders agreed that with further training, community health volunteers were well placed to support these informal centers. Findings showed that given the context of informal settlements, support for strengthening management within the centers in addition to the core domains of WHO's Nurturing Care Framework was required as a key component of the intervention.

Conclusion

Implementing a co-design process embedded within existing community health systems and drawing on the lived experiences of childcare providers and parents in informal settlements facilitated the development of an intervention with the potential for scalability and sustainability. Such interventions are urgently needed as the number of home-based and small center-based informal childcare centers is growing rapidly to meet the demand; yet, they receive little support to improve quality and are largely unregulated. Childcare providers, and government and community health teams were able to co-design an intervention delivered within current public community health structures to support centers in improving nurturing care. Further research on the effectiveness and sustainability of support to private and informal childcare centers in the context of low-income urban neighborhoods is needed.

Impact of DREAMS interventions on experiences of violence among adolescent girls and young women: Findings from population-based cohort studies in Kenya and South Africa

DREAMS aims to reduce HIV incidence among adolescent girls and young women (AGYW) by tackling drivers of HIV risk including gender-based violence. We evaluate the impact of DREAMS on recent experiences of violence perpetuated by men against AGYW. AGYW cohorts were randomly selected from demographic platforms in South Africa (rural KwaZulu-Natal) and Kenya (Nairobi informal settlements and rural Gem sub-county). AGYW aged 13-22 years were enrolled in 2017 (Nairobi, KwaZulu-Natal) or 2018 (Gem), with annual follow-up to 2019. We described proportions of AGYW who self-reported experiences of violence perpetrated by males in the 12 months preceding the interview, overall and by form (physical, sexual, emotional). We investigated associations with DREAMS (invitation to participate during 2017-2018) through multivariable propensity score-adjusted logistic regression and estimated the causal effect of DREAMS on experiences of violence, under counter-factual scenarios in which all versus no AGYW were DREAMS beneficiaries. Among 852, 1018 and 1712 AGYW followed-up in 2019 in Nairobi, Gem and KZN, respectively, proportions reporting any violence in 2019 were higher in Nairobi (29%) than Gem (18%) and KwaZulu-Natal (19%). By sub-type, emotional and physical violence were more frequently reported than sexual violence. We found no evidence of an impact attributable to DREAMS on overall levels of violence, in any setting. Nor was there evidence of impact on sub-types of violence, with one exception: an increase in physical violence in Nairobi if all, versus no, AGYW were DREAMS beneficiaries (16% vs 11%; +5% difference [95% CI: +0.2%, +10.0%]). Experiences of gender-based violence were common among AGYW, especially in urban settings, and DREAMS had no measurable impact on reducing violence within three years of implementation. Violence prevention programming that reaches more men and the broader community, sustained for longer periods, may yield greater gains in violence reduction than AGYW-focused programming. Additionally, more investment in implementation research is needed to bridge trial-based study findings from efficacy to population-level effectiveness.

Physical Activity and Its Association With Body Mass Index: A Cross-Sectional Analysis in Middle-Aged Adults From 4 Sub-Saharan African Countries

BACKGROUND

This study aimed to explore association of self-reported physical activity domains of work, leisure, and transport-related physical activity and body mass index (BMI) in 9388 adult men and women from the Africa-Wits-INDEPTH partnership for Genomic (AWI-Gen) study in Africa. Africa-Wits-INDEPTH partnership for Genomic is a large, population-based cross-sectional cohort with participants from 6 sites from rural and urban areas in 4 sub-Saharan African countries.

METHODS

A sex-stratified meta-analysis of cross-sectional data from men and women aged 29-82 years was used to assess the association of physical activity with BMI.

RESULTS

Overall, meeting physical activity guidelines of at least 150 minutes per week was associated with 0.82 kg/m2 lower BMI in men (β = -0.80 kg/m2; 95% confidence interval [CI], -1.14 to -0.47) and 0.68 kg/m2 lower BMI in women (β = -0.68 kg/m2; 95% CI, -1.03 to -0.33). Sex and site-specific differences were observed in the associations between physical activity domains and BMI. Among those who met physical activity guidelines, there was an inverse association between transport-related physical activity and BMI in men from Nanoro (Burkina Faso) (β = -0.79 kg/m2; 95% CI, -1.25 to -0.33) as well as work-related physical activity and BMI in Navrongo men (Ghana) (β = -0.76 kg/m2; 95% CI, -1.25 to -0.27) and Nanoro women (β = -0.90 kg/m2; 95% CI, -1.44 to -0.36).

CONCLUSIONS

Physical activity may be an effective strategy to curb rising obesity in Africa. More studies are needed to assess the impact of sex and geographic location-specific physical activity interventions on obesity.

Complementarity of formal and informal actors and their networks in support of vulnerable populations in informal settlements: Governance diaries approach

Introduction

Beyond several interests and speculations on the relationship between formal and informal actors and their networks in support of vulnerable populations, most studies do not conclusively establish whether the two types of support are substitutes or complements. While informal care and formal care may be substitutes in general, they are complements among the vulnerable groups. Despite how some studies have described complementarity, further insights on the synergy between formal and informal actors and networks are needed to pinpoint how to maximize policy and interventions to alleviate the challenges facing vulnerable groups in informal settlements.

Methods

We conducted an ethnography using governance diaries with 24 participants in Korogocho and Viwandani informal settlements in Nairobi, Kenya. The governance diaries approach involved conducting bi-weekly governance in-depth interviews (IDIs) with study participants for 4 months, complemented with observations, reflections, participant diaries and informal discussions. We used framework analysis approach.

Findings

Informal actors identified include family, neighbors, friends, community groups and community members, and their direct networks. Formal actors on the other hand included government institutions, individuals and authorities that make policies and rules and their desired and possible networks. Both the formal and informal actors and their networks had complementary roles that were beneficial to the vulnerable populations living and working in informal settlements. The complementarities between formal and informal actors and networks in supporting vulnerable groups were portrayed in roles and responsibilities to the vulnerable groups; rules, regulations and governance in supporting vulnerable groups; knowledge, skills and dynamic workforces among formal and informal actors and their networks; information flow on health and wellbeing to the vulnerable populations; transition of actors in supporting vulnerable groups; availability, access and involvement of formal and informal actors and networks to support vulnerable groups. The complementarities allowed for maximum support of the vulnerable populations than otherwise.

Conclusion

We conclude that informal social support is needed regardless of the availability of formal social support. Moreover, a combination of formal and informal actors and related networks are essential to support vulnerable persons. Formal actors should establish, support, or maintain the informal actors and related networks through goodwill and sundry incentives as a vital dimension of building with local community structures and enhancing inclusion, participation and ownership of policy and program interventions by marginalized and vulnerable groups.

Co-creation and self-evaluation: An accountability mechanism process in water, sanitation and hygiene services delivery in childcare centres in Nairobi's informal settlements

Background

Accountability strategies are expected to enhance access to water, sanitation and hygiene (WASH) service delivery in low-and middle-income countries (LMIC). Conventional formal social accountability mechanisms (SAMs) for WASH service delivery have been inadequate to meet the needs of residents in informal settlements in LMICs. This has prompted growing interest in alternative informal SAMs (iSAMs) in Nairobi's informal settlements. To date, iSAMs have shown a limited effect, often due to implementation failures and poor contextual fit. In childcare centers in Nairobi's informal settlements, co-creation of the iSAMs process, where parents, childcare managers, researchers and other WASH stakeholders, contribute to the design and implementation of iSAMs, is an approach with the potential to meet urgent WASH needs. However, to our knowledge, no study has documented (1) co-creating iSAMs processes for WASH service delivery in childcare centers and (2) self-evaluation of the co-creation process in the informal settlements.

Methods

We used a qualitative approach where we collected data through workshops and focus group discussions to document and inform (a) co-creation processes of SAMs for WASH service delivery in childcare centers and (b) self-evaluation of the co-creation process. We used a framework approach for data analysis informed by Coleman's framework.

Results

Study participants co-created an iSAM process that entailed: definition; action and sharing information; judging and assessing; and learning and adapting iSAMs. The four steps were considered to increase the capability to meet WASH needs in childcare centers. We also documented a self-evaluation appraisal of the iSAM process. Study participants described that the co-creation process could improve understanding, inclusion, ownership and performance in WASH service delivery. Negative appraisals described included financial, structural, social and time constraints.

Conclusion

We conclude that the co-creation process could address contextual barriers which are often overlooked, as it allows understanding of issues through the 'eyes' of people who experience service delivery issues. Further, we conclude that sustainable and equitable WASH service delivery in childcare centers in informal settlements needs research that goes beyond raising awareness to fully engage and co-create to ensure that novel solutions are developed at an appropriate scale to meet specific needs. We recommend that actors should incorporate co-creation in identification of feasible structures for WASH service delivery in childcare centers and other contexts.

Community advisory committee as a facilitator of health and wellbeing: A qualitative study in informal settlements in Nairobi, Kenya

Introduction

A range of community engagement initiatives to advance health and wellbeing are currently taking place in informal settlements in low and middle income countries (LMICs), including community and stakeholder meetings, use of radio, film, TV programs and other information, education and communication materials (IECs) organized by different stakeholders. While these initiatives tend to focus on unidirectional flow of information to communities, the need to incorporate initiatives focusing on bi or multi-directional flow of information have been identified. Despite the extensive body of literature on community engagement, the role of Community Advisory Committees (CACs) in advancing health and wellbeing in informal settlements is still a puzzle, occasioned by considerable ambiguity. A community advisory committee is a dedicated group of volunteers to support health and wellbeing needs of their community using a community approach. Researchers and project implementers work in partnership with CACs to successfully implement their activities within the target community.

Methods

In this paper, using in-depth interviews, we document the roles of CACs in advancing health and wellbeing in Korogocho and Viwandani informal settlements in Nairobi, Kenya.

Results

Study participants described the role of CAC in advancing health and wellbeing through education and awareness creation, advisory roles in research and implementation goals, protecting community interests and acting as gatekeepers and collaborators to community partners. Identified barriers to achieving CAC roles include lack of finance and other field resources, being labeled as organization staff and low involvement by some upcoming and emerging local leaders on issues which involve the CAC constituents. Enablers of CACs in their roles include possession of appropriate skills and values by members; involvement of the community in the selection of members, regular consultative and advisory meetings, representativeness in the composition of CAC membership and knowledge about the community.

Conclusion

We conclude that CACs play key roles in advancing health and wellbeing in informal settlements and that existing CACs mechanisms and operations need to be given due consideration by researchers, project implementers and local authorities right from project conceptualization. CACs need recognition beyond consultations and placations during research and project implementation to a veritable social structure for community's social viability and survival as well as partners in development for inclusive urbanization process. While CACs have contributed in advancing health and wellbeing in informal settlements, there is need for a long-term strategy to optimize their impact and reduce puzzles around their roles.

Carotid intima media thickness (CIMT) in adults in the AWI-Gen Nairobi site study: Profiles and predictors

BACKGROUND

Carotid intima media thickness (CIMT) is used as a marker of subclinical and asymptomatic atherosclerotic vascular disease. Increased CIMT is associated with future cerebrovascular and cardiovascular events. There is limited data on the profile and correlates of CIMT in Africa. The aim of this study was to describe the profile and correlates of CIMT in apparently normal younger-age adults in an urban setting in Kenya.

METHODS

This study used population-based data collected from 2003 adults between the ages of 40 and 60 years in two slums of Nairobi as part of a genetic study. CIMT was measured using LOGIQ e (GE Healthcare, CT, USA) ultrasound on both left and right carotid arteries, whereby maximum, mean, and minimum values were recorded. Age- and sex-specific CIMT measurements were calculated and their association with basic sociodemographic, behavioral and body composition indicators were investigated.

RESULTS

The median (IQR) CIMT were 0.58 (0.51, 0.66) and 0.59 (0.53, 0.66) in men and women, respectively. About 16% of the study population had CIMT greater than 0.7mm, the cut off for higher CIMT. Nearly 60% had CIMT values ≥75th percentile. Age, current use of alcohol, systolic blood pressure, subcutaneous fat thickness, pulse rate and pulse pressure were found to be the main predictors of CIMT in our study population.

CONCLUSION

This study provided population-based reference values and predictors for CIMT for an adult population living in urban poor settings in Kenya. Future studies need to consider biochemical and genetic predictors of CIMT in this population.

Describing the safety of abortion at the population level using network-based survey approaches

BACKGROUND

Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions.

OBJECTIVE

This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted.

METHODS

This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested.

DISCUSSION

This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

SARS-CoV-2 seroprevalence in three Kenyan health and demographic surveillance sites, December 2020-May 2021

BACKGROUND

Most of the studies that have informed the public health response to the COVID-19 pandemic in Kenya have relied on samples that are not representative of the general population. We conducted population-based serosurveys at three Health and Demographic Surveillance Systems (HDSSs) to determine the cumulative incidence of infection with SARS-CoV-2.

METHODS

We selected random age-stratified population-based samples at HDSSs in Kisumu, Nairobi and Kilifi, in Kenya. Blood samples were collected from participants between 01 Dec 2020 and 27 May 2021. No participant had received a COVID-19 vaccine. We tested for IgG antibodies to SARS-CoV-2 spike protein using ELISA. Locally-validated assay sensitivity and specificity were 93% (95% CI 88-96%) and 99% (95% CI 98-99.5%), respectively. We adjusted prevalence estimates using classical methods and Bayesian modelling to account for the sampling scheme and assay performance.

RESULTS

We recruited 2,559 individuals from the three HDSS sites, median age (IQR) 27 (10-78) years and 52% were female. Seroprevalence at all three sites rose steadily during the study period. In Kisumu, Nairobi and Kilifi, seroprevalences (95% CI) at the beginning of the study were 36.0% (28.2-44.4%), 32.4% (23.1-42.4%), and 14.5% (9.1-21%), and respectively; at the end they were 42.0% (34.7-50.0%), 50.2% (39.7-61.1%), and 24.7% (17.5-32.6%), respectively. Seroprevalence was substantially lower among children (<16 years) than among adults at all three sites (p≤0.001).

CONCLUSION

By May 2021 in three broadly representative populations of unvaccinated individuals in Kenya, seroprevalence of anti-SARS-CoV-2 IgG was 25-50%. There was wide variation in cumulative incidence by location and age.

COVID- 19 and human right to food: lived experiences of the urban poor in Kenya with the impacts of government's response measures, a participatory qualitative study

Background

Globally, governments put in place measures to curb the spread of COVID-19. Information on the effects of these measures on the urban poor is limited. This study aimed to explore the lived experiences of the urban poor in Kenya in the context of government’s COVID-19 response measures and its impact on the human right to food.

Methods

A qualitative study was conducted in two informal settlements in Nairobi between January and March 2021. Analysis draws on eight focus group discussions, eight in-depth interviews, 12 key informant interviews, two photovoice sessions and three digital storytelling sessions. Phenomenology was applied to understand an individual’s lived experiences with the human right to food during COVID − 19. Thematic analysis was performed using NVIVO software.

Results

The human right to food was affected in various ways. Many people lost their livelihoods, affecting affordability of food, due to response measures such as social distancing, curfew, and lockdown. The food supply chain was disrupted causing limited availability and access to affordable, safe, adequate, and nutritious food. Consequently, hunger and an increased consumption of low-quality food was reported. Social protection measures were instituted. However, these were inadequate and marred by irregularities. Some households resorted to scavenging food from dumpsites, skipping meals, sex-work, urban-rural migration and depending on food donations to survive. On the positive side, some households resorted to progressive measures such as urban farming and food sharing in the community. Generally, the response measures could have been more sensitive to the human rights of the urban poor.

Conclusions

The government’s COVID-19 restrictive measures exacerbated the already existing vulnerability of the urban poor to food insecurity and violated their human right to food. Future response measures should be executed in ways that respect the human right to food and protect marginalized people from resultant vulnerabilities.

Leaving No One Behind: A Photovoice Case Study on Vulnerability and Wellbeing of Children Heading Households in Two Informal Settlements in Nairobi

Children heading households (CHH) in urban informal settlements face specific vulnerabilities shaped by limitations on their opportunities and capabilities within the context of urban inequities, which affect their wellbeing. We implemented photovoice research with CHHs to explore the intersections between their vulnerabilities and the social and environmental context of Nairobi’s informal settlements. We enrolled and trained four CHHs living in two urban informal settlements—Korogocho and Viwandani—to utilise smartphones to take photos that reflected their experiences of marginalisation and what can be done to address their vulnerabilities. Further, we conducted in-depth interviews with eight more CHHs. We applied White’s wellbeing framework to analyse data. We observed intersections between the different dimensions of wellbeing, which caused the CHHs tremendous stress that affected their mental health, social interactions, school performance and attendance. Key experiences of marginalisation were lack of adequate food and nutrition, hazardous living conditions and stigma from peers due to the limited livelihood opportunities available to them. Despite the hardships, we documented resilience among CHH. Policy action is required to take action to intervene in the generational transfer of poverty, both to improve the life chances of CHHs who have inherited their parents’ marginalisation, and to prevent further transfer of vulnerabilities to their children. This calls for investing in CHHs’ capacity for sustaining livelihoods to support their current and future independence and wellbeing.

Awareness and uptake of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe HIV prevention package over time among population-based cohorts of young women in Kenya and South Africa

OBJECTIVES

To evaluate uptake of a complex intervention for HIV prevention among general populations of adolescent girls and young women (AGYW) in three diverse settings.

DESIGN

Cohorts of ∼1500 AGYW were randomly selected from demographic platforms in Kenya (Nairobi and Siaya) and South Africa (uMkhanyakude, KwaZulu-Natal).

METHODS

AGYW aged 13/15-22 years were enrolled in 2017 (Nairobi and uMkha-nyakude) or 2018 (Siaya), with annual follow-up to 2019. We describe awareness of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe), self-reported invitation to participate, and uptake of DREAMS interventions by: categories and levels of the PEPFAR core package;number of 'primary' interventions (seven in Kenya;five in South Africa). Analyses were stratified by year invited and age at cohort enrolment.

RESULTS

Proportions aware and invited to DREAMS increased across all settings, to ≥ 83% aware and ≥ 53% invited by 2018 (highest among AGYW aged 13-17 years, e.g. 63 vs. 40% among 18-22 s, uMkhanyakude). HIV testing, school-based interventions and social protection were the most accessed categories, while differences in uptake by DREAMS invitation were greatest for novel DREAMS interventions, for example, social asset building (76% among those invited in 2017 and 2018 vs. 9% among those never-invited in Nairobi). Although few DREAMS invitees accessed all intended primary interventions by 2019 (2% of 15-17 s and 5% of 18-22 s in Gem), many accessed at least three interventions, including combinations across individual, family and community levels.

CONCLUSION

Over time, DREAMS reached high proportions of AGYW in all settings, particularly younger AGYW. Participation in combinations of interventions improved but uptake of the complete primary packages remained low.

Establishment of primary health information in the COVID-19 outbreak: A cross-sectional study of population awareness of self-testing

The global pandemic of the Corona Virus Disease 2019 is a severe threat to human health. This paper aims to investigate the status of mass health self-examination awareness and its influencing factors during the COVID-19 epidemic and establish complete health information to intervene in the prevention and control of the COVID-19 epidemic. The study used a simple random sampling method to survey permanent residents (9761 people) aged 15–70 years in a region of Jiangsu Province, China. The survey collected data using a questionnaire with acceptable reliability and validity. The data were entered into SPSS 26, and the data were analyzed using the chi-square test, ANOVA, and logistic regression. The differences in the status of mass health self-examination during COVID-19 were statistically significant (P < 0.05) in terms of the literacy level of the grassroots population, ease of access to medical care, primary medical and health conditions, the situation of medical examination programs, and the construction of primary health information technology. The establishment of comprehensive and systematic primary health information can effectively assist in raising people's awareness of health self-examination and promoting health behaviors, which is essential for enhancing COVID-19 prevention and intervention.

Perspectives on returning individual and aggregate genomic research results to study participants and communities in Kenya: a qualitative study

BACKGROUND

A fundamental ethical challenge in conducting genomics research is the question of what and how individual level genetic findings and aggregate genomic results should be conveyed to research participants and communities. This is within the context of minimal guidance, policies, and experiences, particularly in Africa. The aim of this study was to explore the perspectives of key stakeholders' on returning genomics research results to participants in Kenya.

METHODS

This qualitative study involved focus group discussions (FGDs) and in-depth interviews (IDIs) with 69 stakeholders. The purposively selected participants, included research ethics committee (REC) members (8), community members (44), community resource persons (8), and researchers (9). A semi-structured interview guide was used to facilitate discussions. Six FGDs and twenty-five (IDIs) were conducted among the different stakeholders. The issues explored in the interviews included: (1) views on returning results, (2) kind of results to be returned, (3) value of returning results to participants, and (4) challenges anticipated in returning results to participants and communities. The interviews were audio-recorded, transcribed verbatim, and coded in Nvivo 12 pro. Thematic and content analysis was conducted.

RESULTS

Participants agreed on the importance of returning genomic results either as individual or aggregate results. The most cited reasons for returning of genomic results included recognizing participants' contribution to research, encouraging participation in future research, and increasing the awareness of scientific progress. Other aspects on how genomic research results should be shared included sharing easy to understand results in the shortest time possible and maintaining confidentiality when sharing sensitive results.

CONCLUSIONS

This study identified key stakeholders' perspectives on returning genomic results at the individual and community levels in two urban informal settlements of Nairobi. The majority of the participants expect to receive feedback about their genomic results, and it is an obligation for researchers to see how to best fulfil it.

Impact of the DREAMS Partnership on social support and general self-efficacy among adolescent girls and young women: causal analysis of population-based cohorts in Kenya and South Africa

INTRODUCTION

The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018.

METHODS

Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees.

RESULTS

In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019.

CONCLUSIONS

DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.

Conceptualisations of masculinity and sexual development among boys and young men in Korogocho slum in Kenya

Youth and adolescence are times when young men negotiate their identity in relation to social and cultural expectations of being a man, with enduring implications for sexual health and wellbeing. This study explored how boys aged 10-14 years living in Korogocho slum in Nairobi, Kenya conceptualised masculinity, their perceptions of how masculinities are performed, and the linkage between conceptualisations of masculinity and sexual development. Three bases of gender socialisation were identified: (1) verbal messaging (mainly from parents and teachers); (2) observing the behaviours of older men in the community; and (3) information received from mainstream and social media. Masculinity conceptualisations focussed on financial stability, family life and responsibility, physical attributes, character and religion. Two contrasting portrayals of masculinity emerged in the form of idealised and dominant masculinities. A close linkage was found between masculinity conceptualisations and sexual development. Findings are important for programmes that aim to transform harmful gender norms and signal the need for longitudinal research exploring how gender beliefs may change over time.

Early impact of the DREAMS partnership on young women's knowledge of their HIV status: causal analysis of population-based surveys in Kenya and South Africa

Background

Knowledge of one’s HIV status is the gateway to treatment and prevention, but remains low among young people. We investigated the early impact (2016–2017) of Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a multisectoral HIV prevention package, on knowledge of HIV status among adolescent girls and young women (AGYW).

Methods

In 2017, randomly selected AGYW were enrolled into surveys, N=1081 aged 15–22 years in Nairobi slum settlements, and N=2174 aged 13–22 years in rural KwaZulu-Natal. We estimated the causal effect of being a DREAMS beneficiary on knowledge of HIV status (those who self-reported as HIV-positive or tested HIV-negative in the past year), accounting for an AGYW’s propensity to be a DREAMS beneficiary.

Results

In Nairobi, knowledge of HIV status was higher among DREAMS beneficiaries compared with non-beneficiaries (92% vs 69%, adjusted OR=8.7; 95% CI 5.8 to 12.9), with DREAMS predicted to increase the outcome by 28%, from 65% if none were a DREAMS beneficiary to 93% if all were beneficiaries. The increase attributable to DREAMS was larger among younger participants: 32% and 23% among those aged 15–17 and 18–22 years, respectively. In KwaZulu-Natal, knowledge of status was higher among DREAMS beneficiaries aged 13–17 years (37% vs 26% among non-beneficiaries), with a 9% difference due to DREAMS (95% CI 4.8% to 14.4%), and no evidence of effect among 18–22 years (−2.8%; 95% CI −11.1% to 5.7%).

Conclusion

DREAMS substantially increased knowledge of HIV status among AGYW in Nairobi, and among younger but not older AGYW in KwaZulu-Natal. Adolescent girls can be reached early (before age 18) with community-based HIV testing programmes in diverse high-prevalence settings, with a large impact on the proportion who know their HIV status.

The ethical implications of verbal autopsy: responding to emotional and moral distress

Background

Verbal autopsy is a pragmatic approach for generating cause-of-death data in contexts without well-functioning civil registration and vital statistics systems. It has primarily been conducted in health and demographic surveillance systems (HDSS) in Africa and Asia. Although significant resources have been invested to develop the technical aspects of verbal autopsy, ethical issues have received little attention. We explored the benefits and burdens of verbal autopsy in HDSS settings and identified potential strategies to respond to the ethical issues identified.

Methods

This research was based on a case study approach centred on two contrasting HDSS in Kenya and followed the Mapping-Framing-Shaping Framework for empirical bioethics research. Data were collected through individual interviews, focus group discussions, document reviews and non-participant observations. 115 participants were involved, including 86 community members (HDSS residents and community representatives), and 29 research staff (HDSS managers, researchers, census field workers and verbal autopsy interviewers).

Results

The use of verbal autopsy data for research and public health was described as the most common potential benefit of verbal autopsy in HDSS. Community members mentioned the potential uses of verbal autopsy data in addressing immediate public health problems for the local population while research staff emphasized the benefits of verbal autopsy to research and the wider public. The most prominent burden associated with the verbal autopsy was emotional distress for verbal autopsy interviewers and respondents. Moral events linked to the interview, such as being unsure of the right thing to do (moral uncertainty) or knowing the right thing to do and being constrained from acting (moral constraint), emerged as key causes of emotional distress for verbal autopsy interviewers.

Conclusions

The collection of cause-of-death data through verbal autopsy in HDSS settings presents important ethical and emotional challenges for verbal autopsy interviewers and respondents. These challenges include emotional distress for respondents and moral distress for interviewers. This empirical ethics study provides detailed accounts of the distress caused by verbal autopsy and highlights ethical tensions between potential population benefits and risks to individuals. It includes recommendations for policy and practice to address emotional and moral distress in verbal autopsy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00683-7.

Impact of the DREAMS interventions on educational attainment among adolescent girls and young women: Causal analysis of a prospective cohort in urban Kenya

BACKGROUND

DREAMS promotes a comprehensive HIV prevention approach to reduce HIV incidence among adolescent girls and young women (AGYW). One pathway that DREAMS seeks to impact is to support AGYW to stay in school and achieve secondary education. We assessed the impact of DREAMS on educational outcomes among AGYW in Nairobi, Kenya.

METHODS AND FINDINGS

In two informal settlements in Nairobi, 1081 AGYW aged 15-22 years were randomly selected in 2017 and followed-up to 2019. AGYW reporting invitation to participate in DREAMS during 2017-18 were classified as "DREAMS beneficiaries". Our main outcome was being in school and/or completed lower secondary school in 2019. We used multivariable logistic regression to quantify the association between being a DREAMS beneficiary and the outcome; and a causal inference framework to estimate proportions achieving the outcome if all, versus no, AGYW were DREAMS beneficiaries, adjusting for the propensity to be a DREAMS beneficiary. Of AGYW enrolled in 2017, 79% (852/1081) were followed-up to 2019. In unadjusted analysis, DREAMS beneficiaries had higher attainment than non-beneficiaries (85% vs 75% in school or completed lower secondary school, Odds Ratio (OR) = 1.9; 95%CI: 1.3,2.8). The effect weakened with adjustment for age and other confounders, (adjusted OR = 1.4; 95%CI: 0.9,2.4). From the causal analysis, evidence was weak for an impact of DREAMS (estimated 83% vs 79% in school or completed lower secondary school, if all vs no AGYW were beneficiaries, difference = 4%; 95%CI: -2,11%). Among AGYW out of school at baseline, the estimated differences were 21% (95%CI: -3,43%) among 15-17 year olds; and 4% (95%CI: -8,17%) among 18-22 year olds.

CONCLUSIONS

DREAMS had a modest impact on educational attainment among AGYW in informal settlements in Kenya, by supporting both retention and re-enrolment in school. Larger impact might be achieved if more AGYW were reached with educational subsidies, alongside other DREAMS interventions.

The Chronic Kidney Disease in Africa (CKD-Africa) collaboration: lessons from a new pan-African network

Chronic kidney disease (CKD) is a global public health problem, seemingly affecting individuals from low-income and-middle-income countries (LMICs) disproportionately, especially in sub-Saharan Africa. Despite the growing evidence pointing to an increasing prevalence of CKD across Africa, there has not been an Africa-wide concerted effort to provide reliable estimates that could adequately inform health services planning and policy development to address the consequences of CKD. Therefore, we established the CKD in Africa (CKD-Africa) Collaboration. To date, the network has curated data from 39 studies conducted in 12 African countries, totalling 35 747 participants, of which most are from sub-Saharan Africa. We are, however, continuously seeking further collaborations with other groups who have suitable data to grow the network. Although many successful research consortia exist, few papers have been published (with none from Africa) detailing the challenges faced and lessons learnt in setting up and managing a research consortium. Drawing on our experience, we describe the steps taken and the key factors required to establish a functional collaborative consortium among researchers in Africa. In addition, we present the challenges we encountered in building our network, how we managed those challenges and the benefit of such a collaboration for Africa. Although the CKD-Africa Collaboration is focused primarily on CKD research, many of the lessons learnt can be applied more widely in public health research in LMICs.

A Promising Approach to Preventing Gender-Based Violence and HIV Among Slum-Dwelling Youth in Nairobi, Kenya

Gender-based violence (GBV) and HIV are interrelated public health problems affecting numerous global communities. To date, few prevention initiatives have demonstrated reductions in GBV and HIV, and thus there is an urgency to identify effective strategies to prevent these interconnected public health crises. The purpose of the current article is to describe a gender-enhanced life skills training curriculum (GE-LSTC) currently being developed in Nairobi, Kenya. We discuss previous research relevant to the GE-LSTC; the theoretical underpinnings of the GE-LSTC; the history and context of the GE-LSTC; preliminary implementation, feasibility, and acceptability data on the GE-LSTC; and plans for further refinement and rigorous evaluation of the GE-LSTC.

Towards an appropriate ethics framework for Health and Demographic Surveillance Systems (HDSS): learning from issues faced in diverse HDSS in sub-Saharan Africa

Introduction

Health and Demographic Surveillance Systems (HDSS) collect data on births, deaths and migration from relatively small, geographically defined populations primarily in Africa and Asia. HDSS occupy a grey area between research, healthcare and public health practice and it is unclear how ethics guidance that rely on a research-practice distinction apply to HDSS. This topic has received little attention in the literature. In this paper, based on empirical research across sub-Saharan Africa, we map out key ethical issues for HDSS and assess the relevance of current ethics guidance in relation to these findings.

Methods

We conducted a qualitative study across seven HDSS sites in sub-Saharan Africa, including individual in-depth interviews and informal discussions with 68 research staff, document reviews and non-participant observations of surveillance activities. Qualitative data analysis drew on a framework approach led by a priori and emergent themes, drawing on the wider ethics and social science literature.

Results

There were diverse views on core ethical issues in HDSS, including regarding the strengths and challenges of community engagement, informed consent and data sharing processes. A key emerging issue was unfairness in the overall balance of benefits and burdens for residents and front-line staff when compared with other stakeholders, particularly given the socioeconomic contexts in which HDSS are generally conducted.

Conclusion

We argue that HDSS operate as non-traditional epidemiologic research projects but are often governed using ethics guidance developed for traditional forms of health research. There is a need for specific ethics guidance for HDSS which prioritises considerations around fairness, cost-effectiveness, ancillary care responsibilities, longitudinality and obligations of the global community to HDSS residents.

Estimating the burden of cardiovascular risk in community dwellers over 40 years old in South Africa, Kenya, Burkina Faso and Ghana

Introduction

Cardiovascular disease (CVD) risk factors are increasing in sub-Saharan Africa. The impact of these risk factors on future CVD outcomes and burden is poorly understood. We examined the magnitude of modifiable risk factors, estimated future CVD risk and compared results between three commonly used 10-year CVD risk factor algorithms and their variants in four African countries.

Methods

In the Africa-Wits-INDEPTH partnership for Genomic studies (the AWI-Gen Study), 10 349 randomly sampled individuals aged 40–60 years from six sites participated in a survey, with blood pressure, blood glucose and lipid levels measured. Using these data, 10-year CVD risk estimates using Framingham, Globorisk and WHO-CVD and their office-based variants were generated. Differences in future CVD risk and results by algorithm are described using kappa and coefficients to examine agreement and correlations, respectively.

Results

The 10-year CVD risk across all participants in all sites varied from 2.6% (95% CI: 1.6% to 4.1%) using the WHO-CVD lab algorithm to 6.5% (95% CI: 3.7% to 11.4%) using the Framingham office algorithm, with substantial differences in risk between sites. The highest risk was in South African settings (in urban Soweto: 8.9% (IQR: 5.3–15.3)). Agreement between algorithms was low to moderate (kappa from 0.03 to 0.55) and correlations ranged between 0.28 and 0.70. Depending on the algorithm used, those at high risk (defined as risk of 10-year CVD event >20%) who were under treatment for a modifiable risk factor ranged from 19.2% to 33.9%, with substantial variation by both sex and site.

Conclusion

The African sites in this study are at different stages of an ongoing epidemiological transition as evidenced by both risk factor levels and estimated 10-year CVD risk. There is low correlation and disparate levels of population risk, predicted by different risk algorithms, within sites. Validating existing risk algorithms or designing context-specific 10-year CVD risk algorithms is essential for accurately defining population risk and targeting national policies and individual CVD treatment on the African continent.

Prevalence and socio-demographic correlates of tobacco and alcohol use in four sub-Saharan African countries: a cross-sectional study of middle-aged adults

BACKGROUND

Substance misuse is a global public health problem. In addition to social and economic concerns, consumption of tobacco and alcohol is associated with susceptibility to cardiovascular, respiratory, and infectious diseases, cancers, and risk of transition to substance use disorders. African data suggest regional differences in the prevalence and patterns of substance use, but a number of key questions remain. This cross-sectional population-based study of middle-aged adults aims to examine prevalence and socio-demographic correlates of substance use in four sub-Saharan African countries, in rural and urban settings.

METHODS

Participants aged between 40 and 60 years were recruited from six research centres as part of the Africa Wits-INDEPTH partnership for Genomic Research study. Data on patterns of tobacco and alcohol consumption was captured, and the latter further assessed using the CAGE (cut-annoyed-guilty-eye) questionnaire.

RESULTS

Data from 10,703 participants suggested that more men (68.4%) than women (33.3%) were current substance users. The prevalence of current smoking was significantly higher in men than in women (34.5% vs 2.1%, p < 0.001). Smokeless tobacco was used more by women than men (14.4% vs 5.3%, p < 0.001). Current smoking was associated with alcohol consumption in men, and smoking cessation in men was associated with being a former drinker, having higher socio-economic status, and if married or cohabiting. Current alcohol consumption was higher in men, compared to women (60.3% vs 29.3%), and highest in men from Soweto (70.8%) and women from Nanoro (59.8%). The overall prevalence of problematic alcohol consumption among men was 18.9%, and women 7.3%. Men were significantly more likely to develop problematic drinking patterns, and this was more common in those who were divorced or widowed, and in current smokers.

CONCLUSIONS

Regional variation in the patterns and prevalence of substance use was observed across study sites, and in rural and urban settings. The high levels of substance use recorded in this study are of concern due to the increased risk of associated morbidities. Further longitudinal data will be valuable in determining trends in substance misuse in Africa.

Reaching early adolescents with a complex intervention for HIV prevention: findings from a cohort study to evaluate DREAMS in two informal settlements in Nairobi, Kenya

BACKGROUND

The DREAMS Partnership promotes combination HIV prevention among adolescent girls and young women. We examined the extent to which DREAMS interventions reached early adolescent girls (EAG; aged 10-14 years) in two informal settlements in Nairobi, and the characteristics of those reached, after 3 years of implementation.

METHODS

We utilized three data rounds from a randomly-sampled cohort of EAG established in 2017 in Korogocho and Viwandani informal settlements where DREAMS interventions were implemented. Interventions were classified as individual or contextual-level, with individual interventions further categorised as primary (prioritised for this age group), or secondary. We summarised self-reported invitation to participate in DREAMS, and uptake of eight interventions that were supported by DREAMS, during 2017-2019. Multivariable logistic regression analysis was used to identify individual and household characteristics associated with invitation to DREAMS and uptake of primary interventions.

RESULTS

Data were available for 606, 516 (retention rate of 85%) and 494 (82%) EAG in 2017, 2018 and 2019, respectively. Proportions invited to DREAMS increased from 49% in 2017, to 77% by 2018, and to 88% by 2019. School-based HIV and violence prevention, and HIV testing and counselling were the most accessed interventions (both at 82%). Cumulative uptake of interventions was higher among those invited to participate in DREAMS compared to those never invited, particularly for new interventions such as social asset building and financial capability training. Contextual-level interventions were accessed infrequently. Most of those invited both in 2017 and 2018 accessed ≥3 interventions (96%), and 55% received all three primary interventions by 2019.

CONCLUSIONS

Uptake of DREAMS interventions among a representative sample of EAG was high and quickly increased over the implementation period. The majority accessed multiple interventions, indicating that it is feasible to integrate and deliver a package of interventions to EAG in a challenging informal context.

New Vaccine Introduction and Childhood Vaccination Timeliness in Two Urban, Informal Settlements in Nairobi, Kenya

New vaccine introduction accompanied by social mobilization activities could contribute to improved routine immunization timeliness. This study assesses the impact of Kenya's introduction of pneumococcal conjugate vaccine (PCV) on the timeliness of routine childhood vaccination in two informal, urban settlements in Nairobi. Data collected from 2007 to 2015 as part of a demographic surveillance system were used to estimate annual vaccination delays of ≥ 4 weeks among children aged 12-23 months in the period before and after the introduction of PCV in Kenya. Binomial segmented regression models using generalized estimating equations examined the association between vaccine introduction and timeliness of routine immunization. Over half of all children vaccinated in the two urban areas received one or more doses ≥ 4 weeks after the recommended age. The timeliness of routine immunization showed slight improvements or nonsignificant changes during the years following PCV introduction compared with the preceding years (adjusted prevalence ratio [aPR]: 0.67, 95% CI: 0.45-0.99 for Bacille Calmette-Guerin receipt; aPR: 0.59, 95% CI: 0.41-0.83 for third dose Pentavalent receipt; aPR: 1.19, 95% CI: 0.99-1.42 for measles). However, as of 2015, delayed vaccination remained prevalent in children, particularly among the poorest residing in the settlements. Many sub-Saharan African countries have introduced new life-saving vaccines into their routine childhood immunization schedule. Additional evidence regarding the positive or neutral influence of new vaccine introduction on the performance of delivery systems provides further justification to sustain the inclusion of these more costly vaccines in the immunization schedule.

Patterns and predictors of private and public health care utilization among residents of an informal settlement in Nairobi, Kenya: a cross-sectional study

BACKGROUND

Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya.

METHODS

This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers.

RESULTS

Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11-0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13-4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53-5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00-4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50-5.86) were significantly associated with private facility use compared to other facilities.

CONCLUSIONS

The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.

Malaria is a cause of iron deficiency in African children

Malaria and iron deficiency (ID) are common and interrelated public health problems in African children. Observational data suggest that interrupting malaria transmission reduces the prevalence of ID1. To test the hypothesis that malaria might cause ID, we used sickle cell trait (HbAS, rs334 ), a genetic variant that confers specific protection against malaria2, as an instrumental variable in Mendelian randomization analyses. HbAS was associated with a 30% reduction in ID among children living in malaria-endemic countries in Africa (n = 7,453), but not among individuals living in malaria-free areas (n = 3,818). Genetically predicted malaria risk was associated with an odds ratio of 2.65 for ID per unit increase in the log incidence rate of malaria. This suggests that an intervention that halves the risk of malaria episodes would reduce the prevalence of ID in African children by 49%.

Adiposity Phenotypes and Subclinical Atherosclerosis in Adults from Sub-Saharan Africa: An H3Africa AWI-Gen Study

Background:

Obesity and adipose tissue distribution contribute to an increased risk of cardiovascular disease (CVD) by promoting atherosclerosis. This association has been poorly studied in sub–Saharan Africa (SSA) despite the rising prevalence of cardiovascular disease.

Objectives:

We determined the association between various adiposity phenotypes and carotid intima–media thickness (CIMT), a proxy of subclinical atherosclerosis, in a large SSA population.

Methods:

A population–based cross–sectional study was performed from 2013–2016 in Burkina Faso, Ghana, Kenya and South Africa. Body mass index (BMI), waist (WC), hip circumferences (HC), visceral (VAT) and subcutaneous adipose tissue (SCAT) using B-mode ultrasound were measured. Ultrasonography of left and right far wall CIMT of the common carotid artery was used as an indicator of subclinical atherosclerosis. Individual participant data meta–analyses were used to determine the associations between adiposity phenotypes and CIMT in the pooled sample while adjusted multivariable linear regression analyses were used for site specific analyses.

Results:

Data were obtained from 9,010 adults (50.3% women and a mean age of 50± 6years). Men had higher levels of visceral fat than women while women had higher BMI, waist and hip circumference and subcutaneous fat than men at all sites except Burkina Faso. In the pooled analyses, BMI (β–value [95% CIs]: 19.5 [16.8, 22.3] μm) showed the strongest relationship with CIMT followed by VAT (5.86 [4.65, 7.07] μm), SCAT (5.00 [2.85, 7.15] μm), WC (1.27 [1.09, 1.44] μm) and HC (1.23 [1.04, 1.42] μm). Stronger associations were observed in men than in women.

Conclusion:

Obesity within SSA will likely result in higher levels of atherosclerosis and promote the occurrence of cardio- and cerebrovascular events, especially in males, unless addressed through primary prevention of obesity in both rural and urban communities across Africa. The inverse association of VAT with CIMT in Burkina Faso and Ghana requires further investigation.

Highlights

Maternal and neonatal data collection systems in low- and middle-income countries for maternal vaccines active safety surveillance systems: A scoping review

BACKGROUND

Most post-licensure vaccine pharmacovigilance in low- and middle-income countries (LMICs) are passive reporting systems. These have limited utility for maternal immunization pharmacovigilance in LMIC settings and need to be supplemented with active surveillance. Our study's main objective was to identify existing perinatal data collection systems in LMICs that collect individual information on maternal and neonatal health outcomes and could be developed to inform active safety surveillance of novel vaccines for use during pregnancy.

METHODS

A scoping review was performed following the Arksey and O'Malley six-stage approach. We included studies describing electronic or mixed paper-electronic data collection systems in LMICs, including research networks, electronic medical records, and custom software platforms for health information systems. Medline PubMed, EMBASE, Global Health, Cochrane Library, LILACS, Bibliography of Asian Studies (BAS), and CINAHL were searched through August 2019. We also searched grey literature including through Google and websites of existing relevant perinatal data collection systems, as well as contacted authors of key studies and experts in the field to validate the information and identify additional sources of relevant unpublished information.

RESULTS

A total of 11,817 records were identified. The full texts of 264 records describing 96 data collection systems were assessed for eligibility. Eight perinatal data collection systems met our inclusion criteria: Global Network's Maternal Newborn Health Registry, International Network for the Demographic Evaluation of Populations and their Health; Perinatal Informatic System; Pregnancy Exposure Registry & Birth Defects Surveillance; SmartCare; Open Medical Record System; Open Smart Register Platform and District Health Information Software 2. These selected systems were qualitatively characterized according to seven different domains: governance; system design; system management; data management; data sources, outcomes and data quality.

CONCLUSION

This review provides a list of active maternal and neonatal data collection systems in LMICs and their characteristics as well as their outreach, strengths, and limitations. Findings could potentially help further understand where to obtain population-based high-quality information on outcomes to inform the conduct of maternal immunization active vaccine safety surveillance activities and research in LMICs.

Improving the quality of child-care centres through supportive assessment and 'communities of practice' in informal settlements in Nairobi: protocol of a feasibility study

INTRODUCTION

Investing in children during the critical period between birth and age 5 years can have long-lasting benefits throughout their life. Children in Kenya's urban informal settlements, face significant challenges to healthy development, particularly when their families need to earn a daily wage and cannot care for them during the day. In response, informal and poor quality child-care centres with untrained caregivers have proliferated. We aim to co-design and test the feasibility of a supportive assessment and skills-building for child-care centre providers.

METHODS AND ANALYSIS

A sequential mixed-methods approach will be used. We will map and profile child-care centres in two informal settlements in Nairobi, and complete a brief quality assessment of 50 child-care centres. We will test the feasibility of a supportive assessment skills-building system on 40 child-care centres, beginning with assessing centre-caregivers' knowledge and skills in these centres. This will inform the subsequent co-design process and provide baseline data. Following a policy review, we will use experience-based co-design to develop the supportive assessment process. This will include qualitative interviews with policymakers (n=15), focus groups with parents (n=4 focus group discussions (FGDs)), child-care providers (n=4 FGDs) and joint workshops. To assess feasibility and acceptability, we will observe, record and cost implementation for 6 months. The knowledge/skills questionnaire will be repeated at the end of implementation and results will inform the purposive selection of 10 child-care providers and parents for qualitative interviews. Descriptive statistics and thematic framework approach will respectively be used to analyse quantitative and qualitative data and identify drivers of feasibility.

ETHICS AND DISSEMINATION

The study has been approved by Amref Health Africa's Ethics and Scientific Review Committee (Ref: P7802020 on 20^th April 2020) and the University of York (Ref: HSRGC 20^th March 2020). Findings will be published and continual engagement with decision-makers will embed findings into child-care policy and practice.

Does recall time matter in verbal autopsies? Evidence from urban informal settlements in Nairobi, Kenya

Background: To assign a cause of death to non-medically certified deaths, verbal autopsies (VAs) are widely used to determine the cause of death. The time difference between the death and the VA interview, also referred to as recall time, varies depending on social and operational factors surrounding the death. We investigated the effect of recall time on the assignment of causes of death by VA. Methods: This is a secondary analysis of 2002-2015 survey data of the Nairobi Urban Health Demographic Surveillance System (NUHDSS). The independent variable recall time was derived from the date of death and the date when the VA was conducted. Univariate and multivariate logistic regression methods were used to calculate odds ratios of assigning a cause of death in defined categories of recall time. Results: There were 6218 deaths followed up between 2002 and 2016, out of which 5495 (88.3%) had VAs done. Recall time varied from 1-3001 days (median  92 days, IQR 44-169 days). Majority of the VAs (45.7%) were conducted between 1-3 months after death. The effect of recall time varied for different diseases. Compared to VAs conducted between 1-3 months, there was a 24% higher likelihood of identifying HIV/AIDS as the cause of death for VAs conducted 4-6 months after death (AOR 1.24; 95% CI 1.01-1.54; p-value = 0.043) and a 40% increased chance of identifying other infectious diseases as the cause of death for VAs conducted <1 month after death (AOR 1.4; 95% CI 1.02-1.92, p-value = 0.024). Conclusions: Recall time affected the assignment of VA cause of death for HIV/AIDS, other infectious diseases,maternal/neonatal and indeterminate causes. Our analysis indicates that in the urban informal setting, VAs should be conducted from one month up to 6 months after the death to improve the probability of accurately assigning the cause of death.

Multimorbidity from Chronic Conditions among Adults in Urban Slums: The AWI-Gen Nairobi Site Study Findings

Background:

In the era of double burden of infectious and non-communicable diseases in sub-Saharan Africa, the burden of multimorbidity is likely to be common. However, there is limited evidence on the burden and its associated factors in the sub-Saharan African context.

Objective:

The aim of this study was to determine the levels and identify determinants of multimorbidity from chronic conditions in two urban slums in Nairobi.

Methods:

Data collected from 2003 study participants aged 40–60 years in two urban slums of the Nairobi Urban Health and Demographic Surveillance System in 2015 were used. Using self-report, anthropometry and key biomarkers, data on 16 conditions including chronic diseases, behavioral disorders and metabolic abnormalities were gathered. Lifetime multimorbidity defined by the occurrence of at least two chronic conditions in an individual at any time during their life course was computed. Factors associated with lifetime multimorbidity were identified using multiple logistic regression.

Findings:

A total of 2,081 chronic conditions were identified among 1,302 individuals. While 701 (35.0%) had no chronic condition, single morbidity was reported in 726 (36.2%) of the study population. The overall prevalence of lifetime multimorbidity was 28.7%. The prevalence of dyads and triads of simultaneous occurrences of conditions (episodic multimorbidity) was 20.8% and 6.1%, respectively. Single morbidity was positively associated with gender and alcohol consumption; and negatively associated with employment. Women, older people, the unemployed, current smokers and current alcohol consumers had higher levels of lifetime multimorbidity in the study population.

Interpretation:

The findings of this study indicate that a considerable proportion of adults living in urban slums experience multimorbidity from chronic conditions. Further studies with a better rigor to establish temporal associations between socio-demographic factors and the occurrence of chronic conditions are needed to explore the impacts and implications on health status and health system.

Public knowledge of risk factors and warning signs for cardiovascular disease among young and middle-aged adults in rural Tanzania

Background

Improving cardiovascular health requires public knowledge and reduction of modifiable cardiovascular disease (CVD) risk factors. This study assessed knowledge of risk factors and warning signs for CVDs among young and middle-aged adults in Morogoro, Tanzania.

Methods

We conducted a community-based survey as part of cluster randomized controlled study of community health workers (CHWs) intervention for reduction of blood pressure among young and middle-aged adults in rural Morogoro. Information on socio-demographic characteristics, knowledge of risk factors and warning signs for CVDs was collected using an interviewer administered questionaire. Knowledge was assessed using open-ended questions followed by closed-ended questions. Descriptive statistics were used to describe knowledge of risk factors and warning signs. Logistic regression analysis was used to investigate factors associated with adequate knowledge of risk factors and warning signs for CVDs.

Results

Two-thirds (65.7%) of the participants had heard about CVDs. The main sources of information were mainly relatives/ neighbors (64.8%) and radio (53.0%). Only 28.3% of the participants reported health care providers as source of information about CVDs. More than half of the participants (52.4%) did not mention even one risk factor spontaneously while 55.2% were unable to mention any warning sign. When asked to select from a list, 6.9% were unable to correctly identify any risk factor whereas 11.8% could not correctly identify even a single warning sign. Quarter of participants (25.4%) had good knowledge score of risk factors, 17.5% had good knowledge score of warning signs and 16.3% had overall good knowledge of both risk factors and warning signs. Residing in Ulanga, having higher education level, having ever checked blood pressure and being overweight/obese predicted adequacy of knowledge score for both risk factors and warning signs.

Conclusion

Knowledge of risk factors and warning signs in this rural population of young and middle-aged adults was generally low. Health care providers were less likely to provide health education regarding risk factors and warning signs for CVDs. Health promotion interventions to increase population knowledge of risk factors and warning signs should be implemented for successful reduction of CVDs in Tanzania.

CIDACS-RL: a novel indexing search and scoring-based record linkage system for huge datasets with high accuracy and scalability

Background

Record linkage is the process of identifying and combining records about the same individual from two or more different datasets. While there are many open source and commercial data linkage tools, the volume and complexity of currently available datasets for linkage pose a huge challenge; hence, designing an efficient linkage tool with reasonable accuracy and scalability is required.

Methods

We developed CIDACS-RL (Centre for Data and Knowledge Integration for Health – Record Linkage), a novel iterative deterministic record linkage algorithm based on a combination of indexing search and scoring algorithms (provided by Apache Lucene). We described how the algorithm works and compared its performance with four open source linkage tools (AtyImo, Febrl, FRIL and RecLink) in terms of sensitivity and positive predictive value using gold standard dataset. We also evaluated its accuracy and scalability using a case-study and its scalability and execution time using a simulated cohort in serial (single core) and multi-core (eight core) computation settings.

Results

Overall, CIDACS-RL algorithm had a superior performance: positive predictive value (99.93% versus AtyImo 99.30%, RecLink 99.5%, Febrl 98.86%, and FRIL 96.17%) and sensitivity (99.87% versus AtyImo 98.91%, RecLink 73.75%, Febrl 90.58%, and FRIL 74.66%). In the case study, using a ROC curve to choose the most appropriate cut-off value (0.896), the obtained metrics were: sensitivity = 92.5% (95% CI 92.07–92.99), specificity = 93.5% (95% CI 93.08–93.8) and area under the curve (AUC) = 97% (95% CI 96.97–97.35). The multi-core computation was about four times faster (150 seconds) than the serial setting (550 seconds) when using a dataset of 20 million records.

Conclusion

CIDACS-RL algorithm is an innovative linkage tool for huge datasets, with higher accuracy, improved scalability, and substantially shorter execution time compared to other existing linkage tools. In addition, CIDACS-RL can be deployed on standard computers without the need for high-speed processors and distributed infrastructures.

Adolescents' narratives of coping with unintended pregnancy in Nairobi's informal settlements

Aim

This study explored adolescent experiences and coping strategies for unintended pregnancy in two informal settlements—Viwandani and Korogocho—in Nairobi, Kenya.

Methods

Forty-nine in-depth-interviews and eight focus group discussions were conducted with male and female adolescents aged 15–19 years from households in two informal settlements. Participants were purposively selected to include adolescents of varying socio-demographic characteristics, including the married and unmarried, and adolescents who had never/ever been pregnant. Data were transcribed, translated verbatim and analyzed thematically.

Results

Adolescents attributed unintended pregnancy to poverty, sexual violence and inconsistent contraceptive use. Lack of parental support and guidance, as well as household conflicts also exposed girls to early sexual debut and risky sexual behavior. Decisions about pregnancy management centered on carrying the pregnancy to term or terminating it. Deciding to terminate a pregnancy was not always straightforward and was motivated by concerns about stigma or shame, and school disruption. Participants reiterated that carrying an unintended pregnancy to term disrupts adolescents’ schooling, with few girls returning to school after childbirth. Upon deciding to carry a pregnancy to term, adolescents used several coping strategies such as relocating from usual residence, hiding until delivery and planning to put up the child for adoption upon delivery.

Conclusions

Early interventions to provide adolescents with comprehensive pregnancy prevention information and to address sexual violence and poverty can prevent unintended pregnancy in adolescents. Efforts to support adolescents to positively cope with unintended pregnancy and facilitate re-entry to school are also warranted.

Complete and on-time routine childhood immunisation: determinants and association with severe morbidity in urban informal settlements, Nairobi, Kenya

Background: Completion of the full series of childhood vaccines on-time is crucial to ensuring greater protection against vaccine-preventable diseases.Aim: To examine determinants of complete and on-time vaccination and evaluate the relationship between vaccination patterns and severe morbidity outcomes.Subjects and methods: Vaccination information from infants in Nairobi Urban Health and Demographic Surveillance System was used to evaluate full and on-time vaccination coverage of routine immunisation. Logistic regression was used to identify determinants of full and on-time vaccination coverage. Cox regression model was used to evaluate the relationship between vaccination status and subsequent severe morbidity. A shared frailty cox model was fitted to account for the heterogeneity in hospitalisation episodes.Results: Maternal age, post-natal care, parity, ethnicity, and residence place were identified as determinants of vaccination completion. Institutional deliveries and residence place were identified as the determinants of on-time vaccination. A significant 58% (confidence interval [CI]: 15-79%) (p = .017) lower mortality was observed among fully immunised children compared with not fully immunised. Lower mortality was observed among on-time immunised children, 64% (CI: 20-84%) compared to those with delays.Conclusions: Improving vaccination timeliness and completion schedule is critical for protection against vaccine preventable diseases and may potentially provide protection beyond these targets.

Does recall time matter in verbal autopsies? Evidence from urban informal settlements in Nairobi, Kenya

Background: To assign a cause of death to non-medically certified deaths, verbal autopsies (VAs) are widely used to determine the cause of death. The time difference between the death and the VA interview, also referred to as recall time, varies depending on social and operational factors surrounding the death. We investigated the effect of recall time on the assignment of causes of death by VA. Methods: This is a secondary analysis of 2002-2015 survey data of the Nairobi Urban Health Demographic Surveillance System (NUHDSS). The independent variable recall time was derived from the date of death and the date when the VA was conducted. Univariate and multivariate logistic regression methods were used to calculate odds ratios of assigning a cause of death in defined categories of recall time. Results: There were 6218 deaths followed up between 2002 and 2016, out of which 5495 (88.3%) had VAs done. Recall time varied from 1-3001 days (mean 115.5 days, sd216.8). Majority of the VAs (45.7%) were conducted between 1-3 months after death. The effect of recall time varied for different diseases. Compared to VAs conducted between 1-3 months, there was a 24% higher likelihood of identifying HIV/AIDS as the cause of death for VAs conducted 4-6 months after death (AOR 1.24; 95% CI 1.01-1.54; p-value = 0.043) and a 40% increased chance of identifying other infectious diseases as the cause of death for VAs conducted <1 month after death (AOR 1.4; 95% CI 1.02-1.92, p-value = 0.024). Conclusions: Recall time affected the assignment of VA cause of death for HIV/AIDS, other infectious diseases and maternal/neonatal causes. Our analysis indicates that in the urban informal setting, VAs should be conducted from one month up to 6 months after the death to improve the probability of accurately assigning the cause of death.